While eating disorders may begin with preoccupations with food and weight, they're most often about much more than food.

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Eating disorders are complex conditions that arise from a combination of:

• long-standing behavioral, emotional, psychological, interpersonal and social factors

Scientists and researchers are still learning about the underlying causes of these emotionally and physically damaging conditions.

We do know, however, about some of the general issues that can contribute to the development of eating disorders.

People with eating disorders often use food and the control of food in an attempt to compensate for feelings and emotions that may otherwise seem overwhelming.

For some, dieting, bingeing and purging may begin as a way to cope with painful emotions and to feel in control of one’s life, but ultimately, these behaviors will damage a person’s physical and emotional health, self-esteem and sense of competence and control.

• commitment
• competence 
• structure
  

COMMITMENT: (goes to make a point about commitment on the additional info on eating disorder's page!)

Most of us believe when we decide to make a change in our lives that we're fully committed to doing what it takes to make that change happen.

But commitment can be a tricky thing.

There can be part of us who is truly committed to the change, while there may be other parts of us who have no desire to change.

This phenomenon is known as having "competing commitments".

Competing commitments create resistance and having to deal with resistance is what often causes us to give up before we reach our goal.

Example: Megan wants to start an exercise program to lose weight and increase her energy level. She signs up for a class at health club and is excited about getting started. The first few mornings go well, but then she begins to notice that her enthusiasm is waning.

Megan begins to sabotage her progress by skipping classes and telling herself that her instructor isn’t really sensitive to her needs. She feels that she's still committed to losing weight and doesn't really understand where her resistance is coming from.

Resistance is the red flag for competing commitments. In Megan's case the competing commitment turned out to be her desire to spend time with her friends. She had a weekly get-together that she assumed she no longer could attend because she had to get up early in the morning to exercise.

Megan saw her dilemma as an either/or situation. She believed that she would have to give up one activity in order to have the other.

Once she realized that that wasn’t actually true – that her friends would be willing to change their meeting time – Megan began to relax and her resistance disappeared.

COMPETENCE:

The 2nd key element is competence. Competence means having the skills necessary to make the change happen, or having the time, energy and ability needed to acquire the skill.

Example:
Lucy was having trouble at work with one of her workers, Kris. Every time Lucy would try and talk to Kris about her negative attitude, the conversation would end up very heated and both women would leave feeling upset and unheard.

Lucy was committed to finding a way to try and help Kris see how her attitude was affecting her team and the whole organization.

After several less-than-satisfactory attempts at trying to solve the problem herself, Lucy realized that she wasn't as skilled at having these kinds of conversations as she needed to be. At this point she had to decide whether or not she wanted to commit to strengthening her ability to have difficult conversations.

Lucy knew she was capable of learning what was needed and she was committed to seeing her problem through; so she decided to hire a consultant to help her address the situation.

STRUCTURE:

The last element is structure. Structure is the most important element in making change happen, but it's very often overlooked.

Structure is what holds the change process together. It refers to any resources you might need, such as Megan's exercise class or Lucy’s consultant. It also refers to the systems needed to support you as you're working through your change.

Structure provides the safety net. It allows you to share the burden of change with others, therefore lightening your load. It also helps ensure success, as a team effort is usually more successful than one person going it alone.

Who do you call when you're feeling stuck, discouraged, or you want to quit?

Who do you celebrate with when you're successful?

Who'll be there to prod you, encourage you and remind you how great you are and that what you're doing is wonderful?

However, we often forget to put this piece into place and then we're left to face the struggles by ourselves.

We can become overwhelmed and give up feeling defeated and discouraged. Making sure you have a strong structure in place to support you through your change can keep this from happening.

Although the process of change is often described as difficult, it also can be an incredibly exciting journey.

Change is the source of energy that keeps us moving forward and allows us to discover new things about ourselves and our world. But, as with all journeys, the better you prepare for it, the smoother your trip will be.

So, the next time you're faced with a change, make sure you're clear about your commitment, realistic about your competence and that you've taken the time to create a solid structure to support you. I think you'll be pleasantly surprised with the end results.

Some people with eating disorders say they feel smothered in overprotective families.

Others feel

• abandoned
• misunderstood
• alone

Parents who over-value physical appearance can unwittingly contribute to an eating disorder. So can those who make critical comments, even in jest, about their children's bodies.

Families that include a person with an eating disorder tend to be overprotective, rigid and ineffective at resolving conflict.

Sometimes mothers are emotionally cool while fathers are physically or emotionally absent.

They include:

• odd feeding schedules
• using food for rewards
• punishments
• comfort
• other non-nutritive purposes
• concerns about their daughters' weight

Still to be determined is whether or not daughters of mothers with eating disorders will themselves become eating disordered when they reach adolescence.

Also, if mothers & fathers preach & nag about junk food & try to limit their children's access to treats, the children will desire & overeat these very items.  (click here to read other info)

A recent study (American Journal of Clinical Nutrition. 2003;78:215) indicates that when parents restrict eating, children are more likely to eat when they're not hungry.

The more severe the restriction, the stronger the desire to eat prohibited foods. These behaviors may set the stage for a full blown eating disorder in the future.

The ONPRC also participates in the voluntary accreditation program overseen by the Association for Assessment & Accreditation of Laboratory Animal Care International (AAALAC).

It can affect other family members as well. Being seriously underweight can lead to depression & social withdrawal. The individual can become irritable & easily upset & have difficulty interacting with others.

Sleep can become disrupted & lead to fatigue during the day. Attention & concentration can decrease. All of these features can negatively affect one's daily activities.

Diminished interest in previously preferred activities can result. Some individuals also have symptoms that meet the criteria for a Major Depressive Disorder.

They think about it constantly & become compulsive about eating rituals. They may collect recipes or hoard food. Additionally, they may exhibit other obsessions &/or compulsions related to food, weight, or body shape that meet the criteria for an Obsessive-Compulsive Disorder.

Generally, individuals w/anorexia are compliant. Sometimes, they are overly compliant, to the extent that they lack adequate self- perception.

They're eager to please & strive for perfection. They usually do well in school & may often overextend themselves in a variety of activities. The families of anorexics often appear to be "perfect." Physical appearances are important to them. Performance in other areas is stressed as well & they're often high achievers.

While control & perfection are critical issues for individuals w/anorexia, aspects other than their eating habits are often found to be out of control as well. Many have, or have had at some point in their lives, addictions to alcohol, drugs, or gambling. Compulsions involving sex, exercising, housework & shopping aren't uncommon.

Most of the medical complications of anorexia nervosa result from starvation. Few organs are spared the progressive deterioration brought about by anorexia.

Although not life-threatening, abnormally slow heart action (bradycardia) & unusually low blood pressure (hypotension) are frequent manifestations of starvation & are commonly associated with anorexia.

Of greater significance are disturbances in the heart rate (arrhythmia). A reduction in the work capacity of the heart is associated with severe weight loss & starvation.

Gastrointestinal complications are also associated with anorexia. Constipation & abdominal pain are the most common symptoms. The rate at which food is absorbed into the body is slowed down.

Starvation & overuse of laxatives can seriously disrupt the body's normal functions involved in the elimination process. While liver function is generally found to be normal, there is evidence of enzyme changes & overall damage to the liver.

The glandular (endocrine) system in the body is profoundly affected by anorexia. The complex physical & chemical processes involved in the maintenance of life can be disrupted, with serious consequences.

Disturbances in the menstrual cycle are frequent & can affect not only child-bearing but also bone density growth, which is very important to a woman's health as she ages. Hormonal imbalances are found in men with anorexia as well. Continual restrictive eating can trick the thyroid into thinking that the body is starving, causing it to slow down in an attempt to preserve calories.

Kidney (renal) function may be thought to be normal. However, there are significant changes in many patients, resulting in:

• potassium deficiency
• increased urination
• decreased urination

Anorexics who use a large quantity of laxatives or who frequently vomit are at great risk for electrolyte imbalance, which can have life-threatening consequences.

Anemia is frequently found in anorexic patients. Suppressed immunity & a high risk for infection are suspected, but not clinically proven.

Physical symptoms, other than the obvious loss of weight, can be seen. Anorexia can cause:

• dry, flaky skin that takes on a yellow tinge
• fine, downy hair grows on the face, back, arms & legs

Despite this new hair growth, loss of hair on the head isn't uncommon.

• nails can become brittle
• frequent vomiting can erode dental enamel & eventually lead to tooth loss

Most of the medical complications of anorexia nervosa result from starvation. Few organs are spared the progressive deterioration brought about by anorexia.

• Heart & circulatory system: Although not life-threatening, abnormally slow heart action (bradycardia) & unusually low blood pressure (hypotension) are frequent manifestations of starvation & are commonly associated with anorexia.

Of greater significance are disturbances in the heart rate (arrhythmia). A reduction in the work capacity of the heart is associated with severe weight loss & starvation.

• Gastrointestinal complications are also associated with anorexia. Constipation & abdominal pain are the most common symptoms.

The rate at which food is absorbed into the body is slowed down. Starvation & overuse of laxatives can seriously disrupt the body's normal functions involved in the elimination process. While liver function is generally found to be normal, there's evidence of enzyme changes & overall damage to the liver.

• The glandular (endocrine) system in the body is profoundly affected by anorexia. The complex physical & chemical processes involved in the maintenance of life can be disrupted, with serious consequences.

Disturbances in the menstrual cycle are frequent & can affect not only fertility but also bone density growth, which is very important to a woman's health as she ages.

Hormonal imbalances are found in men with anorexia as well. Continual restrictive eating can trick the thyroid into thinking that the body is starving, causing it to slow down in an attempt to preserve calories.

• Kidney (renal) function may appear normal. However, there are significant changes in kidney function in many people with anorexia, resulting in potassium deficiency, increased urination, or decreased urination.

• Anorexics who use a large quantity of laxatives or who frequently vomit are at great risk for electrolyte imbalance, which can have life-threatening consequences.

• Anemia is frequently found in anorexic patients. Suppressed immunity & a high risk for infection are suspected, but not clinically proven.

• Physical symptoms, other than the obvious loss of weight, can be seen. Anorexia can cause dry, flaky skin that takes on a yellow tinge. Fine, downy hair grows on the face, back, arms & legs.

Despite this new hair growth, loss of hair on the head isn't uncommon. Nails can become brittle. Frequent vomiting can erode dental enamel & eventually lead to tooth loss

• From his viewing chair, a father criticizes a television personality for "how fat she looks" in her evening gown.

Anorexia nervosa has been reported beginning at age 4. Childhood anorexia should fulfill criteria for adolescent or adult onset anorexia nervosa, except that in children, due to a diminished amount of body fat, a 25% weight loss isn't necessary.

In female childhood cases, primary amenorrhea occurs.

The incidence of prepubertal anorexia nervosa is 3% in a series of 600 consecutive patients of all ages evaluated for anorexia nervosa at the Mayo Clinic (5).

Females comprise 73% of all reported children w/anorexia nervosa (4).

However, in one subgroup of anorectics (see below), 50% were males (6).

Developmental antecedents of childhood anorexia haven't been systematically research (7). Delaney & Silber (8) evaluated approximately 30 cases & noted lack of stage specific negativism at age 2, anxious clinging behavior upon commencement of school, & difficulty maintaining peer relations, leading to a degree of social isolation.

In infants ages nine to 29 months, Chatoor & Egan (9) described a developmental disturbance which they consider to be both a separation disorder & a form of infantile anorexia. These infants were noted to have a diminished growth rate & food refusal.

Feeding became a battleground for maternal-infant autonomy struggles. The infants resisted feeding as a manifestation of their independence from an overwhelmingly strong maternal figure.

The child's fight for independence thru anorexic behavior is sharply contrated to the listless marasmic pattern that characterizes the withdrawn underfeeding in anaclitic depression (10).

Latency-age children, at the Piagetian stage of concrete thinking, conceptualize food & water together as one entity, resulting in global ingestive restriction. This may lead to rapid weight loss & serious dehydration.

In addition, prepubertal children, especially girls, have less body fat than their adolescent counterparts & become more quickly emaciated (11). In Irwin's series, over 2/3 of the children w/ anorexia were hospitalized within 6 months of the onset of the anorexia.

Gislason (4) noted one death in 33 children w/ prepubertal anorexia nervosa.

Sargent (6) described 3 subgroups of prepubertal anorectics.

The first group, similar to one described by Pugliese et al. (12) severely restricted their food intake, resulting in short stature. They had fears of becoming obese & by their deficient weight gain they maintained both a physical & psychological immaturity.

The second group consisted primarily of prepubertal females, ages 10 to 12, who were psychologically pseudo-precocious, engaging in overt behavior more characteristic of that of a pubescent 14 year-old.

However, they were described as being "lost little girls" underneath this facade. Their parents discouraged age-appropriate behavior & strongly encouraged their pseudo-adolescent behavior. This female subgroup is closet to the pubertal-onset anorexia nervosa.

The third subgroup consisted of an equal number of male & female anorectics who were more psychologically impaired, having major ego deficits w/ the occasional prescence of psychotic episodes (13).

Gislason (4) noted premorbid personality characteristics of:

• dependency
• timidity
• schizoid traits
• w/ features of depression

Significant disturbances of ego development, prepsychotic personality traits & psychotic episodes have been reported (4).

However, these studies were completed prior to the more precise DSM III diagnostic criteria. Moreover, premorbid eating disturbances, including a history of being a finicky eater, have been noted (11).

Family patterns in childhood anorexia nervosa haven't been systematically studied.

Family structural characteristics found in adolescent anorexia nervosa, consisting of:

• rigidity
• lack of conflict resolution
• triangulation

appear to be present in the families of children w/ the disorder (11).

In childhood anorexia, Sargent (6) noted increased divorce among families, as contrasted to adolescent anorexia where the family divorce rate is approximately equal to the general population.

The clinical manifestation of childhood anorexia nervosa should fulfill most DSM III criteria. However, since prepubertal children, especially girls, have less body fat than their adolescent counterparts, a 15% reduction in body weight should be sufficient for diagnosis (11,14).

These children, while recognizing that they're thin, deny feeling fat. It's unclear if there's a body image distortion equivalent to that of older anorectics.

Furthermore, no systematic comparative studies in children have been undertaken. The child may be more concerned w/ separation individuation issues than fears of sexuality (11,15). They frequently demonstrate alexithymia, the inability to translate one's feelings into words (16).

Overt or covert seduction or sexual abuse may be found in the histories of some patients, although Bruch (17), Blinder (18) & Piazza (19) question this hypothesis.

Sloan & Leichner (20) reported childhood sexual abuse in a number of adult patients w/ bulimia nervosa. Oppenheimer et al. (21) reported that 2/3 of 78 eating disorder patients spoke of distressing sexual experiences as a child, including sexual abuse. However, the significance of a history of sexual abuse for the occurrence of anorexia nervosa remains unclear.

Many children with anorexia nervosa manifested signs of depression. These feelings may be the result of helplessness & ineffectiveness internally perceived & mirrored from family attitudinal reactions.

Studies reported prior to DSM III did not utilize structured interviews such as Kiddie SADS. In child anorectics, no formalized studies specifying biochemical, diagnostic, or family criteria for major depressive disorders have been reported.

While anorexia nervosa has been considered a variant of affective disorder (22,23), the relationship between childhood anorexia nervosa & affective disorder must still be clarified.

Anorexia nervosa has been associated w/ Tourette's Syndrome (stereotyped movement disorder) (24,25,26) w/ Turner's Syndrome, a chromosome disorder w/ XO genotype & gonadal dysgenesis (27) & w/ mental retardation (28).

Piazza (19) reported anorexia nervosa in association w/ childhood ulcerative colitis & ileitis. The patient manifested typical bowel symptoms w/diminished appetite & only upon careful questioning was the diagnosis of anorexia nervosa determined.

One child had anorexia nervosa & abdominal complaints which initially masked colitis.

The etiology of childhood anorexia is uncertain. Irwin (11) feels dynamics in childhood anorexia nervosa are similar to the dynamics of adolescent onset & include:

• identity disturbance
• failure of separation/individuation w/ fears of growing up
• maladaptive attempts to be in control
• failure of parents to resolve marital or family conflicts

An alternative pattern may include a child who is sensitive to family food preoccupation & identifies w/ a family member who has an eating disturbance.

Precipitating events associated with the onset of childhood anorexia nervosa include:

1) the birth of a sibling

2) bereavement over the death of a parent or relative

3) a disappointment in object relations

4) family discord

5) viral illness

6) peer criticism about being fat

7) the fear of becoming obese

8) the onset of breast development

9) sexual abuse

10) sustained fear of choking while eating

11) anticipated fear of parental loss related to an ill or depressed parent

12) the onset of a psychophysiologic disorder such as ulcerative colitis (4).

In the treatment of the childhood anorectic, the therapist should work closely w/ a pediatrician to rule out medical & psychological conditions producing anorexia. A physical examination & laboratory studies are mandatory to monitor starvation effects which include:

1) hypotension

2) syncope

3) bradycardia

4) hypothermia

5) dry skin

6) lanugo hair

7) diminished triceps skin-fold thickness

8) hypoglycemia

9) hair loss

10) sensitivity to noise

11) leukopenia

12) fatigue

13) cardiac arrhythmia

14) electrolyte disturbance

15) hypothalamic dysfunction

16) diminished thermoregulation

17) hypercortisolism

18) vasopressor regulation

19) gastric ulcer

20) initial motoric hyperactivity

Starvation can cause psychological & cognitive disturbances including:

• food preoccupation
• poor concentration
• social isolation
• depression
• labile moods (29)

Children, especially those restricting both fluids & food, may need immediate hospitalization. A children's inpatient psychiatric unit can be effective in resolving both physiologic & psychological problems (15,30).

The dietician must determine the appropriate caloric intake for the child. Calories & nutrients not ingested due to food refusal must be supplemented by liquid intensive formula per mouth, or by tube feeding if necessary.

Parenteral hyperalimentation is rarely necessary for childhood anorexia.

Most children's psychiatric inpatient unit use flexible behavioral modification approaches to weight gain. Unlike adolescent or adult behavioral programs, children should be allowed to attend all ward activities regardless of specific weight gain (15).

Overactivity on the ward must be monitored & controlled to avoid weight loss. Panikar (31) used a wheelchair to restrain a severely overactive child. The schizoid, withdrawn child can be rewarded w/points, tokens, etc., for engaging in verbally expressive social interaction.

More intensive involvement of the family in the therapeutic pain may have to await medical stabilization & emerging data concerning developmental history, effects of separation (positive & negative) & family strengths & liabilities.

Play therapy using projective techniques can be useful. While children ages 10 thru 12 may feel too old for play therapy, they may not be cognitively prepared for verbal therapy. They may also be resistant in therapy; therefore, therapeutic creativity is needed. Panikar (16), noting alexithymia, draws smiling faces & asks the children to identify various moods.

Affective expression can be encouraged, such as in Gardner's "Thinking, Talking & Feeling Game" (32). Lucas (33) finds art therapy to be particularly effective when compared to play therapy which the anorectic child often resists & obscures.

Feinstein (34) alternating both male & female therapists, recognizes that the child can work thru separate conflicts w/different therapists.

Sargent (6) modifies treatment according to the 3 anorexic subgroups described above.

In the first group of anorectics, w/ growth retardation described by Pugliese et al. (12) the social worker & nutritionist meet on a regular basis to improve caloric intake. Pugliese uses a cognitive approach, informing the children that they need to eat to be strong & grow.

In Sargent's (6) second group of precocious females, individual psychotherapy explores the child's underlying separation, identity & sexual conflicts  & her need to recognize feelings of ineffectiveness & confusion. The parents must recognize their need to push their daughter into premature adolescence & must work with a dietician to promote normal caloric intake.

In the third group, the therapist must assist the child in recognizing his own sense of worth & must establish a strong therapeutic alliance encouraging normal ego development, interpreting, countering & ameliorating what may be a chaotic enviornment in the family. The parents, often having severe psychopathology, need to resolve their own conflicts  to stabilize the family.

With such a family setting, a period of hospital separation may be a beneficial opportunity for clarification, intensive therapeutic focus on the child & emergency of diagnostically significant elements of family psychopathology masked by the dramatic nature of the child's anorexia.

Chatoor (35), in her treatment of infantile anorexia, uses 10 food rules, including restricting a specific meal time to 30 minutes & refraining from emotionally laden comments. The goal is to allow the infant to reexperience hunger in a neutral, time-limited setting. In some cases, the mother may need to work thru her own internal conflicts (9).

The prognosis in childhood anorexia is unclear. Sargent feels that the group II females have less individual & family psychopathology & have the most favorable outcome as contrasted to group III, since both individual & parental psychopathology are severe.

The group I prognosis is intermediate between groups II & III. Delaney & Silber (8) noted male anorectics w/ a poor prognosis & reported that many families have been resistant to follow-up. Gislason (4) summarized & reported cases of prepubertal anorexia & noted that 63% improved, 21% didn't improve & 3% died.

Russell (36) found prolonged delay of puberty (a late menarche) & possible permanent interference w/ growth in stature & breast development in children w/ prepubertal anorexia nervosa. In contrast, Pfeiffer, et al (37), noted relatively minimal growth retardation on a several-year followup of treatment.

He stresses the importance of identifying childhood anorexia nervosa & returning the children to an optimum weight to safeguard their puberty. A long-term followup is necessary to accurately determine prognosis.

Anorexia nervosa has been reported in prepubertal children, many of whom appear to be more disturbed than adolescents with the same disorder. The precise etiology is uncertain, but life events centering on losses & separation may be onset factors.

Due to less body fat & ingestive restriction of both food & water, this disorder may be more ominous in children, necessitating a rapid & vigorous therapy & frequently requiring inpatient treatment. Prognosis is guarded & uncertain.

Furthermore, coexistent medical illnesses, colitis, or ileitis require careful physical examination & diagnostic procedures & comprehensive integrated treatment & management.

About one-third of all Americans are overweight, and not all of them are binge eaters. Most of us find ourselves eating too much at one time or another. At Thanksgiving, or other special occasions, it is very common for us to consume 1,000 or more calories at a sitting, and often to continue eating even after we feel full. Often we feel we have made a bit of a pig of ourselves. But that does not mean that every American has binge eating disorder.

What separates overeating from binge eating disorder is:

Signs and Symptoms of Binge Eating Disorder

Are any of these true for you?

• Some days even though I wanted to stop eating, I just could not help myself.
• Some days I surprise myself with how much food I can eat in just a very short span of time.
• I feel so horrible and guilty after I realize how much food I have consumed.
• It seems that every night I go to bed thinking, “Tomorrow I am going to begin my diet.”